Kyrgyzstan: Officials Grapple with HIV Outbreak

Southern Kyrgyzstan became the site of the latest in a series of recent Central Asian HIV outbreaks, with at least 26 people, mostly children, infected in two local hospitals. Experts hope that the combined impact of the wave of infections will serve as a wake-up call for a dysfunctional and impoverished healthcare system, but some warn of a misdirected government response.

Unofficial counts put the number of infected children at over 30, and a preliminary investigation concluded in late August by the US Centers for Disease Control (CDC) estimated that the figure would eventually reach 100. This would put the Kyrgyz outbreak in the range of a similar occurrence in Shymkent, Kazakhstan, where since 2006 a total of 133 children have tested positive for HIV. [For background see the Eurasia Insight archive].

"Unsafe injections, poor quality of blood safety, and ... lousy sterilization of multiple-use medical instruments" were the main causes of the virus' spread in both cases, said Michael Favorov, Regional Director of the CDC's Central Asia office.

Health officials believe that the source of the Kyrgyz outbreak was a sick child admitted to the local hospital in the town of Nookat, who had gotten the virus either from his mother, or via a contaminated blood transfusion. The infection spread to the Osh regional pediatric hospital, and perhaps further, as ill, HIV-positive children shuffled from one institution to another.

Four health officials from southern Kyrgyzstan were fired for their alleged roles in the outbreak, including the directors of the two hospitals. The Kyrgyz General Prosecutor's office has opened a criminal investigation into the incident.

Sagynaly Mamatov, director of Kyrgyzstan's National AIDS Center, noted that a government commission had uncovered such high-risk practices in the hospitals as the transfer of blood directly from person to person and the re-use of unsterilized or single-injection needles.

"During an inspection," he said, "we came upon used, unclean syringes in the refrigerator. We said, 'Why are you holding these?' [and the hospital workers replied] 'We haven't had time to throw them out yet.' One can't exclude that these needles were used multiple times," Mamatov said.

Experts said that the deeper cause of the outbreak was a general lack of funding for healthcare in post-Soviet countries. Aging equipment and a shortage of medical supplies prompt doctors to make do with what they have. The extremely low salaries paid to healthcare workers also lead some to use single-use equipment multiple times, as they sell the surplus to supplement their incomes. (Patients in Kyrgyz hospitals usually must purchase their own supplies prior to treatment, often from the doctors themselves).

Bishkek's Adilet legal clinic is providing free representation to one of the dismissed workers, as well as advising some Osh-based groups that are working to support the infected children's families. Erik Iriskulbekov, the clinic's project coordinator, said healthcare providers frequently cut corners to survive. "A syringe costs two to five som [roughly 10 US cents]," meaning a doctor who pockets a single one "already has the ability to buy a loaf of bread."

Sanjar Isaev, a health expert in the Kyrgyz prime minister's office, agreed that fresh supplies were often a temptation for doctors. "I can't say people were [definitely] re-selling, but perhaps low salaries" were a factor, he said. "But in the first place I would put very weak control from the Osh public health structures."

The Osh region has the highest prevalence of registered HIV cases in the country, most of them due to injecting drug use. Mamatov from the AIDS center noted that outbreaks of the virus had previously occurred in the area, most recently in 2005, adding that they were poorly investigated. "If there was some noise at that moment," Mamatov said, "maybe the incident which came to light this year would never have happened."

Iriskulbekov agreed that the guilty parties should be made an example of, but warned against creating "scapegoats" out of the mid-ranking officials who had already been dismissed. "In my opinion, the true people who permitted negligence have not yet been brought to account," he said, adding that the net should be cast both "higher" and "more broadly."

Favorov of the CDC said the Kyrgyz response had been swift from an epidemiological perspective. "The Kyrgyz government, at least at the current stage, is very open and allowed international groups to be involved," said Favorov, although he said it remained to be seen if that "transparency" would extend to the level of the average practitioner on the ground.

Kyrgyzstan's poverty distinguished it from the Shymkent case, Favorov continued. "My major concern is that as a result of that investigation, Kazakhstan put a lot of funds to the prevention and control of that outbreak," he said, whereas Kyrgyzstan would have to seek outside donor support for a similar response.

Indeed, the government's plan – which envisions antiretroviral treatment, counseling, and social support for the infected, an overhaul of blood handling and testing procedures, and public information campaigns – relies heavily on international groups.

In the past, many Kyrgyz AIDS donors have focused on preventing the spread of the virus through work with vulnerable groups such as drug users and sex workers. But Mamatov said the Nookat outbreak underlined a need to emphasize treatment as well. "All the time – prevention, prevention, prevention – but we need to accept that we've lost" that battle, Mamatov said. "We need to work on prevention, but also help the infected."